Courageous Kidz - A Safe Haven for Kids with Cancer

If you have a Courageous Kid in your home,
please fill out this form and join the gang!

CANCER CHILD'S NAME:			Age:
Date of Birth:			NICKNAME:
Address:			City:
State:			Zip Code:
Home Phone:			Work Phone:
Cell Phone:			E-Mail Address:
HOBBIES:

Parents
MOM'S NAME			DAD'S NAME:
Mom's occupation			Dad's Occupation
HOME TELEPHONE			HOME TELEPHONE
WORK PHONE			WORK PHONE
CELL PHONE			CELL PHONE
E-MAIL ADDRESS:			E-MAIL ADDRESS:
Siblings
NAME:			DOB:
NAME:			DOB:
NAME:			DOB:
NAME:			DOB:
NAME:			DOB:

TYPE OF CANCER:			DATE OF DIAGNOSIS:
CURRENT TREATMENT STATUS:	Remission		In treatment	Off treatment
	Relapsed	When?
TREATMENT PROTOCOL:			BLOOD TYPE:
HOSPITAL AFFILIATION:			DOCTOR'S NAME:
DOES YOUR CHILD HAVE ANY SPECIAL NEEDS WE NEED TO BE AWARE OF?
HOW BEST MAY WE SERVE YOU?	Parent Support		Family Support	Sibling Issues
COMMENTS: